DEPARTMENT OF HEALTH SERVICESSTATE OF WISCONSIN

Division of Health Care Access and AccountabilityDHS 107.10(2), Wis. Admin. Code

F-00142 (10/14)

FORWARDHEALTH

PRIOR AUTHORIZATION DRUG ATTACHMENT FOR SYNAGIS®

Instructions: Type or print clearly. Refer to the Prior Authorization Drug Attachment for Synagis® Completion Instructions, F-00142A, for more information.

Providers may call the Drug Authorization and PolicyOverrideCenter at (800) 947-9627 with questions.

SECTION I — MEMBER AND PROVIDER INFORMATION
1. Name — Member (Last, First, Middle Initial)
2. Member Identification Number / 3. Date of Birth — Member
4. Name — Prescriber / 5. National Provider Identifier (NPI) — Prescriber
6. Address — Prescriber (Street, City, State, ZIP+4 Code)
7. Telephone Number — Prescriber
8. Name — Billing Provider / 9. NPI — Billing Provider
SECTION II — CLINICAL INFORMATION FOR ALL PA REQUESTS
10. Was Synagis® administered when the child was hospitalized? YesNo
If yes, indicate the date(s) of administration in the space(s) provided. (No more than five doses will be authorized, inclusive of any hospital-administered doses.)
1. 2. 3.
11. Current Weight — Child (In kilograms) / 12. Date Child Weighed
13. Calculated Dosage of Synagis® (15 milligrams per kilogram of body weight)
Providers are required to complete one of either Section III A, III B, III C, III D, III E, or III F (depending on the child’s medical condition) for a prior authorization (PA) request to be considered for approval.
SECTION III A — CLINICAL INFORMATION FOR CHRONIC LUNG DISEASE
14. The child has chronic lung disease of prematurity.YesNo
15. Did the child require oxygen at greater than 21 percent for at least the first 28 days
after birth? YesNo
16. Indicate the child’s gestational age at delivery (in weeks and days).
Weeks Days
17. Check all therapies below that the child has continuously used over the past six months.
CorticosteroidDiureticSupplemental Oxygen

Continued

PRIOR AUTHORIZATION DRUG ATTACHMENT FOR SYNAGIS®2 of 2

F-00142 (10/14)

SECTION III B — CLINICAL INFORMATION FOR CONGENITAL HEART DISEASE
18. The child is younger than 12 months of age at the start of the respiratory syncytial virus
(RSV) season and has hemodynamically significant congenital heart disease.YesNo
SECTION III C — CLINICAL INFORMATION FOR CARDIAC TRANSPLANT
19. The child is younger than 24 months of age at the start of the RSV season and is
scheduled to undergo a cardiac transplantation during the RSV season.YesNo
SECTION III D — CLINICAL INFORMATION FOR PRE-TERM INFANTS
20. The child is younger than 12 months of age at the start of the RSV season and
was born before 29 weeks gestation (i.e., zero days through 28 weeks, six days). YesNo
Indicate the child’s gestational age at delivery (in weeks and days).
Weeks Days
SECTION IIIE — CLINICAL INFORMATION FOR PULMONARY ABNORMALITIES AND NEUROMUSCULAR DISEASE
21. The childis younger than 12 months of age at the start of the RSV season and has a
neuromuscular disease or congenital abnormality that impairs the ability to clear secretions
from the upper airway because of an ineffective cough. YesNo
If yes, indicate the disease or anomaly.
SECTION III F — CLINICAL INFORMATION FOR IMMUNOCOMPROMISED CHILDREN
22. The childis younger than 24 months of age at the start of the RSV season and is profoundly immunocompromised due tothe following:
a. Solid Organ TransplantYesNo
b. Stem Cell TransplantYesNo
c. Receiving Chemotherapy YesNo
d. Acquired Immune Deficiency Syndrome (AIDS)YesNo
e. Other YesNo
If other, indicate the cause of the child’s immunodeficiency.
SECTION IV — AUTHORIZED SIGNATURE
23. SIGNATURE —Prescriber / 24. Date Signed — Prescriber
SECTION V — ADDITIONAL INFORMATION
25. Indicate any additional information in the space provided. Additional diagnostic and clinical information explaining the need for the product requested may be included here.